Repeated warnings

Each one is a single concern, raised with the same organisation in two or more coroners' reports at least six months apart. Nemotron Super judged every match to be the same or a closely related hazard, and both quotes are checked word for word against the reports.

Organisation type

Ambulance service25 Commissioner6 Company or provider10 Local authority28 National body342 NHS body Police28 Prison or detention12 Other40

Theme

Care homes28 Child deaths64 Custody and policing46 Drugs, alcohol and medication32 Emergency and community care46 Hospital care108 Mental health72 Products and workplaces9 Roads and rail53 Suicide Other11

Relation

Identical Closely related

Reports

3+ reports

More filters

Minimum confidence

0.80+0.90+

At least

5 reports 10 reports

Active:NHS body Suicide Confidence 0.90+Clear all

24 chains, most recent report first. The order is by date only; there is no ranking of organisations.

Untrained staff conducting mental health assessments
Mid and South Essex NHS Foundation Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.92 · high
Inadequate discharge decision analysis
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Assumption about capacity context
Pennine Care NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Fragmented communication between mental and physical health services
Southern Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.90 · high
Inaccurate or falsified patient observations
East London NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate discharge planning processes
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate transfer assessment and documentation
Betsi Cadwaladr University Health Board · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Insufficient mental health service engagement and follow-up
South West Yorkshire Partnership NHS Foundation Trust · NHS body
3 reports · 3 coroners
Closely relatedConfidence 0.90 · high
Inadequate support for autistic prisoners in crisis
Devon Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust · NHS body
3 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Delayed access to medical records
Essex Partnership University NHS Foundation Trust · NHS body
2 reports · 2 coroners
Identical hazardConfidence 0.92 · highNo published response to an earlier report
Risk assessment not updated with patient history
Oxford Health NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.92 · high
Inadequate verification of leave conditions
Coventry and Warwickshire Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Incomplete and inaccessible clinical records
Cwm Taf Morgannwg University Health Board · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Lack of post discharge support for high risk patients
Leicestershire Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · highNo published response to an earlier report
Inadequate serious incident investigation process
Leicestershire Partnership NHS Trust · NHS body
2 reports · 1 coroner
Closely relatedConfidence 0.90 · high
Limited family involvement in care planning and risk assessment
Nottinghamshire Healthcare NHS Foundation Trust · NHS body
2 reports · 1 coroner
Identical hazardConfidence 0.90 · high
Missing prior suicide attempt information
Devon Partnership NHS Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Lack of rolling risk assessment documentation in SystemOne
Birmingham and Solihull Mental Health Foundation · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high
Inadequate transfer of suicide risk information
Blackpool Teaching Hospitals NHS Foundation Trust · NHS body
2 reports · 2 coroners
Closely relatedConfidence 0.90 · high

All chains